I will never forget traveling with my niece over a decade ago from Melbourne to Sydney after she had received a B-Cell infusion to treat a chronic illness.
By Catherine Beadnell
The new treatment was exciting because it promised to provide more targeted relief than the oral chemotherapy and steroidal treatments she had received for many years.
Several hours after her treatment we set off for Sydney and she mentioned not feeling well. By the time we arrived at my sister’s home in the western suburbs my niece was in extreme pain.
We drove a short distance to the emergency department of a major tertiary hospital and the triage nurses attended to her quickly. As we waited her pain levels worsened, and she became increasingly distressed. This was a young woman who never complained about her illness or the chronic pain she suffered, so we knew things weren’t good.
After what seemed like a very long time, a registrar came to examine my niece. An amazing nurse had been checking in while we waited, and she returned during the doctor’s examination. By now my niece was crying in pain and the registrar was going to prescribe Panadol while some tests were ordered.
I looked across at my sister in exasperation, I’m not medically trained but it seemed something a little stronger might be considered in this situation.
The nurse asked the doctor if she could speak with him and they left the cubicle. A few minutes later the nurse returned with a much stronger pain medication. She was an experienced emergency nurse, and it turns out a great patient advocate, who collaborated with the registrar to ensure my niece received an appropriate response to her level of pain.
I have never forgotten that incident and the enormous gratitude I felt for the nurse as my niece’s pain subsided. It turns out she was allergic to the penicillin administered following her infusion in Melbourne. She remained in hospital overnight until the symptoms subsided.
While the nurse who cared for my niece didn’t prescribe her pain relief she clearly intervened to advocate for her patient and the registrar respected her advice and ordered a more appropriate medicine. It made perfect sense because the nurse was with my niece for a good hour before the doctor arrived and was able to assess her pain levels and advise on the best pharmaceutical response.
Prescribing by nurses well established
There is nothing new about nurses prescribing medicines. The Health Practitioner Regulation National Law Act allows the endorsement of registered nurses and midwives as qualified to prescribe, supply or use scheduled medicines if they meet the requirements of their registration standards.
The introduction of the Nurse Practitioner (NP) role in Australia in 2000 allowed autonomous prescribing by endorsed nurses with Masters’ level education in a speciality area. In 2010 endorsed midwives could also prescribe autonomously under the Registration standard: Endorsement for scheduled medicines for midwives.
Many countries around the world have expanded nurse and midwife prescribing models in place. The United States introduced nurse practitioner roles in the 1960s. In addition to the United States, independent or collaborative prescribing models for nurses and midwives exist in Sweden, the United Kingdom, Canada, Ireland, New Zealand and more recently Australia.
Dr Rosemary Bryant recently joined NPS MedicineWise, representing the nursing and midwifery professions. Dr Bryant was Australia’s first Commonwealth Chief Nursing Officer and is passionate about advancing nursing and midwifery professions.
Changes to prescribing models ‘timely’
Dr Bryant says moves underway to expand the prescribing rights of nurses and midwives are timely and essential for the future of the Australian healthcare system.
“We are certainly not the first country to look at this issue. Countries like the US, UK, Ireland and many others have had expanded prescribing roles for nurses for many years.
“In many ways we are catching up with international trends and it is clear primary healthcare has received a lot of attention in recent years. One of the main reasons for this is that we have an ageing population and all of the complexity that comes with that. A lot of nurses work in primary healthcare and could be doing a lot more to improve health outcomes for people in our communities.”
Dr Bryant says there are multiple reasons for developing new models for nurse and midwife prescribing in the Australian context.
“It makes sense for so many reasons,” she says. “It would be more convenient for patients and it would also help decrease the cost of healthcare in the federal budget.
“If you could have a nurse, with the appropriate level of skill and education, seeing patients and providing continuing scripts for existing conditions for example it would be very convenient for the patient. They may not be initiating medications, but it would be great if they could renew existing scripts.”
Improving access to healthcare
ANMF Senior Professional Officer, Julianne Bryce agrees and says nurses already leave their undergraduate programs with a level of preparation for administering nurse initiated medicines under protocol.
“What happens when you’re working as a nurse is that you might have a standing order from a doctor that allows you to choose between different levels of pain relief. We are not technically prescribing but certainly making decisions about appropriate medication.
“Nurses also already make a lot of decisions around the amount of medication that is administered within a sliding scale. So, we currently have a number of pathways within standing orders and protocols that allow nurses to use their initiative.”
Ms Bryce says the current review of prescribing rights by the Nursing and Midwifery Board of Australia (NMBA) and the Australian and New Zealand Council of Chief Nursing and Midwifery Officers (ANZCCNMO) is an opportunity to address future challenges in the healthcare system.
“This really is an opportunity to improve scope of practice for nurses and midwives across all healthcare settings. We think that acute care is less of an issue because there are lots of doctors in the system. But the reality is a lot of people wait for care due to the availability and access to doctors.
“It’s really important that we have nurses and midwives working to their full scope of practice as the demands on our healthcare system increase. We have an ageing population with increased acuity and nurses are well placed to respond to their needs. Nurses focus on person centred care and it makes sense that we are better equipped to manage medications to prevent delays and deterioration in a person’s health.”
Reaching out to people in need
Gabrielle Bennett is a registered nurse who has spent most of her working life delivering healthcare to people who struggle to access the same level of care that most of us take for granted.
She has worked in remote locations, with people experiencing homelessness and with refugees.
Gabrielle’s current role is Victorian Viral Hepatitis Educator, based at St Vincent’s Hospital in Melbourne.
She supports expanded prescribing roles for nurses and midwives and says new models will potentially improve access to quality healthcare within disadvantaged communities.
“Nurses are already doing this in some areas under arrangements with doctors and nurse practitioners because we have trusting, collaborative relationships. I think it would be good to formalise these arrangements.”
She says hepatitis nurses are already working in collaborative arrangements to provide new, curative drugs with few side effects to people with hepatitis C.
“We’ve got nurse led models happening in prisons and doing outreach to places where people with hepatitis C are attending like needle syringe programs and homelessness services for example.
“We know nurses are doing this work in collaboration with medical specialists and making decisions around which particular drugs people need. Nurses tend to go to places where there are few doctors, like the services I mentioned earlier.”
Gabrielle says the new models of prescribing will extend nurses ability to provide essential healthcare service to people in need. Nurses often communicate on a different level and can spend more time building rapport, finding out what is most important to the client.
“We need to formalise arrangements that are already happening and acknowledge that nurses have the skills and capacity to improve our healthcare system. Particularly in areas of existing disadvantage.”
Symposium identifies strong support for enhanced prescribing roles
A symposium hosted by the Commonwealth Department of Health, on the future of nurse and midwife prescribing was held in Canberra in March 2017. The event attracted over 120 representatives from the clinical, management, nursing research, professional and third sector.
In the final outcomes report in May 2017, Chief Nurse and Midwifery Officer Debra Thoms said the symposium, “identified strong support for enhancing the role the professions currently play in the management of medicines by expanding the ability to prescribe.
“Participants highlighted many ways nurse/midwife prescribing will enhance access to medicines for Australian communities and contribute to improved health outcomes, particularly for underserved populations such as rural and remote and indigenous communities,” she said.
CRANAplus Director of Professional Services, Geri Malone is a registered nurse and midwife who has worked extensively in rural and remote communities in Australia. In her capacity as part of the rural and remote healthcare workforce and with CRANAplus, she is well positioned to see the benefits of new and expanded prescribing rights for nurses and midwives.
Ms Malone says CRANAplus has been advocating for enhanced nurse and midwife prescribing roles for many years.
“This kind of reform is vitally important, particularly for the remote workforce. Access to quality healthcare and medicines for people who live in remote areas is impacted by workforce issues,” she says. “The ability for nurses on the ground to provide better healthcare will definitely improve access and healthcare outcomes in remote areas.”
Ms Malone says any reforms around expanding nurse and midwife prescribing rights must focus on national standards in relation to education, clinical governance, safety and harmonisation of poisons legislation.
“Innovation is usually born of necessity and while we certainly think the reforms will improve access there needs to be a nationally consistent approach. You currently have jurisdictional based drugs and poisons Acts and this has been highlighted as a barrier for some time.
“Our [CRANAplus] position is very much about safe, quality access to medicines for consumers. And we’re aware of the challenge that presents, particularly in remote and rural settings,” she says.
“We support moves that allow nurses and midwives to work to their full scope of practice within guidelines that ensure safe access. It has to be a national approach that makes it easier for a very mobile remote workforce. We have nurses and midwives doing the same work across state and territory borders with different drugs and poisons Acts. These barriers have to be removed by harmonising the laws.”
In its submission to the NMBA/ANZCCNMO public consultation on registered nurse and midwife prescribing, the ANMF also identified the need for a harmonised approach to any new models of nurse and midwife prescribing in Australia. It proposes:
Before a model of independent prescribing for registered nurses could be considered, there would need to be a nationally agreed mechanism by which it is possible to determine that the registered nurse is working as an advanced practice nurse. A national framework to support advanced practice needs to be established as the foundation for a move to broadening independent prescribing…
Once this advanced practice framework is in place, benefits to expanding the model of independent prescribing for registered nurses could be realised and the advantages would include: person-centred care; reduced wait times; system efficiency; cost effectiveness; workforce flexibility; job satisfaction; and improved workforce retention.
This expanded model of independent prescribing would have immense potential to improve timely access to high quality, safe healthcare…
State and Territory Drugs and Poisons legislation and regulations must enable or be amended to support partnership prescribing by registered nurses.
Julianne Bryce says safety, person-centred care and national consistency are issues at the core of the ANMF’s approach to expanded prescribing rights for nurses and midwives in Australia.
“It is vital that we get this right and put the safety of the people whom we provide care for at the core. We’re not suggesting every nurse and midwife is going to have access to the entire PBS. There are some situations where shared care arrangements are essential.
“State and territory health departments operate different frameworks and apply different legislation within their local health workforce settings. Because of this you might be a nurse working across a state border in a remote setting who isn’t able to provide continuity of care across jurisdictions. This is why the various Drugs and Poisons laws should be harmonised.”
New nurse and midwife prescribing models will certainly impact on nursing specialties and as already mentioned have the potential to improve access to improved healthcare across the board.
The current NMBA/ANZCCNMO discussion focusses on three models of prescribing for nurses and midwives in future (the three levels of prescribing model is supported by the ANMF):
Level 1 – Structured prescribing
(NMBA Model 3)
Prescribing occurs where a prescriber with a limited authorisation to prescribe medicines by legislation, requirements of the national Board and policies of the jurisdiction or health service, prescribes medicines under a guideline, protocol or standing order.
Level 2 – Partnership prescribing
(NMBA Model 2)
Prescribing occurs where a prescriber undertakes prescribing within their scope of practice in partnership with an authorised independent prescriber. The partnership prescriber has been educated to prescribe and has a limited authorisation to prescribe medicines by legislation, requirements of the national Board and policies of the jurisdiction, employer or health service. The partnership prescriber recognises their role in the healthcare team and ensures appropriate communication occurs between team members and the person taking the medicine.
Level 3 – Independent prescribing
(NMBA Model 1)
Prescribing occurs where a prescriber undertakes prescribing within their scope of practice without the approval or supervision of another health practitioner. The prescriber has been educated and authorised to independently prescribe in a specific area of clinical practice. Although the prescriber may prescribe independently, they recognise the role of all members of the healthcare team and ensure appropriate communication occurs between team members and the person taking the medicine. This model of prescribing is currently within the scope of practice of nurse practitioners and midwives with scheduled medicines endorsement.
Andrew Cashin is a Nurse Practitioner specialising in mental health and a Professor of Nursing at Southern Cross University.
Professor Cashin supports an expanded prescribing role for nurses and midwives under supervision, akin to the NMBA Model 2 outlined above.
“It would be great to have registered nurses expanding their roles in prescribing in partnership. I say that because autonomous prescribing requires the advanced clinical skills and diagnostic reasoning in the nurse practitioner scope of practice. Having registered nurses prescribing in partnership with nurse practitioners for example would be great for improving access to and quality of healthcare,” he says.
“I make mention of the quality angle because nursing is largely a person-centred model. Patients talk about how nurses spend more time with them and understand their healthcare needs. As long as registered nurses complete further education and work in partnership with autonomous (or independent) prescribers it will certainly make a difference.”
People experiencing mental health issues face a lot of barriers in accessing treatment and lack confidence in the system, according to Professor Cashin. Expanded roles for mental health nurses and partnership prescribing models with nurse and medical practitioners could improve both access and quality of care.
“We know that a large number of people with mental health issues aren’t receiving adequate treatment. I think the proposed changes will rationalise the approach to prescribing including ceasing some medications. We could provide better access, not only to medicines, but to the right medicine and the right dose”.
“Another important aspect of this is allowing nurses an expanded role in mental health from a person-centred care approach. Nurses have a great role to play in preparing people to be at the centre of their own care and educating them in medication management. In mental health you think about issues like choice to take medication and adherence to medicines. Nurses can work with people to action quality medication choices and save a whole lot of unwanted side effects and it will also save the country money. ”
Summary of Key Outcomes
Registered Nurse/Midwife Prescribing Symposium 2017
- Overall support for extending capacity for some form of prescribing across the nursing and midwifery professions beyond that currently held by NPs and endorsed midwives.
- Potential benefits in the use of nurse/midwife prescribing across various aspects of healthcare delivery including:
- Improved access
- Health outcomes and cost effectiveness
- More effective use of resources
- Greater contribution to the quality use of medicines
- Improved patient experience
- All healthcare settings were seen to benefit from a new model of prescribing with community, aged care and rural and remote settings scoring slightly higher than others.
- Majority of responses (n=68) said the ability for nurses and midwives to prescribe would enhance access to medicines by increasing the opportunity for individuals to obtain the medicines they require and by reducing the time, effort and cost it might otherwise take for them to do so. (Source – Registered Nurse/Midwife Prescribing Symposium: Final outcomes report May 2017) Note: Based on Commonwealth of Australia (Department of Health) material
To read more articles from ANMJ, view the full journal online at https://issuu.com/australiannursingfederation/docs/anmj_march_18_issuu